The Knee Society Total Knee Arthroplasty Roentgenographic

Evaluation and Scoring System

Frederick C. Ewald, MD, on behalf of The Knee Society

(Used with permission by Lippincott Williams & Wilkins. This article

originally appeared in Clin Orthop. 1989 Nov;(248):9-12. PMID:
2805502)

A roentgenographic knee evaluation system endorsed by The Knee

Society is included in this years proceedings to encourage uniform
reporting of the results of total knee arthroplasty. No rating system is
ideal, but if many surgeons and centers use the same reporting
system, then relative comparisons will at least become possible.
Agreement on a new system by many experienced surgeons and
institutions with a large clinical volume represents a sacrifice because
old rating system data will have to be discarded.

The Knee Society Roetgenographic Evaluation System was

developed for uniform reporting of roentgenographic results of total
knee arthroplasty so comparisons could be made not only between
different institutions but also between different implants. The
important aspects of successful arthroplasty are featured in the
system, such as component position, leg and knee alignment, and
the prosthesis-bone interface or fixation. The system is easy to use,
fast, and is on one sheet of paper. In addition to measurement of
knee alignment and component position, the system has a numerical
score for the prosthetic interface that assesses the quality of fixation.
Those features that convert an image into numbers will enable
roentgenographic results to be stored in a data base along with the
clinical results. Up to this time, most computerized total joint
registries have only stored clinical results.

The main disadvantage to this system is standardization of

roentgenograms for the proper position, rotation, and alignment of the
knee. This positioning error can be reduced if the examiners use
multiple sets of knee roentgenograms and select the most
representative films from which to take measurements.

MATERIALS AND METHODS

The knee is positioned in a standard manner. A 101.6-cm tube-to-
film distance is used. The consensus at two Knee Society meetings
(February 20, 1986, and September 10, 1986) regarding fluoroscopic
positioning and the use of 91.44-cm cassettes for alignment films was
that these techniques are not mandatory. However, if they are used,
it should be recorded.

The leg is positioned so the patella points directly toward the ceiling
with the patient supine. For the anteroposterior (AP) view, the beam
is directed perpendicular to the midshaft of the femur and tibia and
pointing directly at the joint line, which is determined by palpation.
For the lateral view, the knee and extremity are positioned in the
same manner except the x-ray beam is directed laterally, 90 degrees
to the AP view. The joint line is determined in the same way.

The tibial interface is to be examined and evaluated in the AP and

lateral views and the femoral interface in the lateral view. The patella
will be evaluated in the skyline or Merchant view. Standing views at a
101.6-cm tube-to-film distance or a 182.88-cm tube distance will not
be used for the bone-cement evaluation because positioning of the
prosthesis is often difficult.

In the AP view of the tibia, seven zones are delineated with Zones 5,
6, and 7 reserved for the fixation stem of any length or multiple stems
if present. The consensus at The Knee Society meeting of
September 10, 1986, was that the number and location of the zones
to be examined will be established by the prime developers of any
particular knee design. An example of a tibial plateau interface
fixation zonal assignment system is seen in Figure 1.

In the lateral view of the femur, seven zones are evaluated with
Zones 5, 6, and 7 representing the fixation stem or stems, whatever
the length. With no stem, Zones 5, 6, and 7 represent the central
area. An example of zone assignment for the lateral view of the
femoral component is seen in Figure 2.

The patella is viewed in skyline or in the Merchant view. Three to five

zones should be assigned with Zones 3, 4 and 5 representing the lug
fixation, whether it is single or multiple lugs.
If any problems exist with the patellofemoral joint, then additional
measurements should be taken, such as (1) the angle of prosthesis in
the patellar body remnant: (2) prosthetic placement (mediolateral on
skyline view and superoinferior on lateral knee view): (3) amount of
subluxation on skyline: and (4) presence of complete dislocation on
skyline. An example of zone systems for the patella is seen in Figure
3.

RESULTS

The scoring system for each of the three components is determined

by measuring the width of the radiolucent lines for each of the zones
in millimeters for each of the three components. The total widths are
added for each zone for each of the three prostheses. The total
produces a numerical score for each component. There may be five
to seven zones assigned for the tibia and femur and three to five
zones for the patella. This score can be rated as follows for a seven-
zone tibial component: 4 or less and nonprogressive is probably not
significant: 5-9 should be closely followed for progression; and 10 or
greater signifies possible or impending failure regardless of
symptoms.

DISCUSSION

A migrating or shifting prosthesis with or without disappearance of

radiolucent lines or bone-prosthesis or bone-cement interface should
be considered as a possible or impending failure regardless of the
above score. Prosthetic position can be estimated by the enclosed
system of angle measurements. Direct subsidence without angular
movement cannot be detected because there is no reference point.
Knee valgus can be measured by the longitudinal midmedullary lines
of the tibia and femur on the AP, standing, or 91.44-cm cassette
roentgenogram.

The silhouette of the prosthesis used by an institution can be

substituted in Figure 4. Zones assigned by the developer then should
be used by everyone evaluating that particular implant design.
FIG. 1. AP view of representative tibial component. Other variations
can be a flat tibial component and a long- or multiple-stem tibial
component baseplate. Suggested guidelines for assignment of zone
are: 1 and 2 for medial plateau, 3 and 4 for the lateal plateau, and 5
7 for the stem fixation. If there are no stems, then the central part of
the tibial plateau should be assigned Zones 5-7.

FIG. 2. Lateral view of a representative femoral component. Other

variations can be represented by a long stem or no stems.
Suggested zone assignment is for Zones 1-2 to be reserved for the
anterior flange, Zones 3-4 for the posterior area, and Zones 5-7 for
either the stem or the central portion if there is no stem.
FIG. 3. These diagrams represent patellar skyline view with Zone 1
representing the medial side and Zone 2 the lateral, Zones 3-5 are
reserved for fixation lugs or the central part of the patellar component.
The designer-developer should use his or her discretion to establish
appropriate zones using these guidelines for the design.
FIG. 4. Onepage Knee Society Roentgenographic Evaluation and
Scoring System. Individual designer-developers should substitute
their own prosthetic silhouette and assign zones at the bottom of the
form.